1st nf care moderate mdm 35
CPT 99305 covers the first visit a physician makes to evaluate a patient who has just been admitted to a nursing facility or skilled nursing facility when the medical decision-making is moderately complex.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Bill 99305 only once per patient per facility admission; subsequent visits use 99307-99310
Impact: Billing 99305 twice for same admission results in automatic denial of second claim at $128.42 loss
Document total time on date of encounter (typically 35 minutes) as alternative to MDM for level selection
Impact: Time-based billing provides alternative pathway to justify 99305 level when MDM documentation is borderline, protecting $128.42 vs $92.48 for 99304
Ensure visit occurs within required timeframe after admission (typically within 24-48 hours depending on payer)
Impact: Late initial visits may be downcoded to subsequent nursing facility care codes (99307-99310) resulting in $30-50 reduction
Document moderate complexity MDM elements: multiple problems, moderate data review, or moderate risk
Impact: Insufficient MDM documentation triggers downcoding to 99304 ($92.48), a loss of $35.94 per encounter
Verify patient is in qualifying facility type (SNF/NF); assisted living may not qualify
Impact: Incorrect facility designation results in denial; rebill as office visit code at potentially lower rates
Coordinate with other providers to avoid duplicate billing when multiple physicians see patient on admission day
Impact: Only one initial nursing facility care code per day per patient; duplicate claims denied at full $128.42
Common denials
Billing 99305 more than once during the same facility stay
How to appeal: Submit medical records showing patient was discharged and re-admitted to facility as new admission; include discharge and re-admission dates with documentation showing distinct episodes of care
Insufficient documentation of moderate complexity medical decision-making
How to appeal: Provide detailed audit response highlighting documented elements meeting moderate MDM: number/complexity of problems addressed, amount/complexity of data reviewed, and risk of complications. Reference 2023 E/M guidelines showing two of three MDM elements met moderate threshold
Visit performed outside acceptable timeframe after facility admission
How to appeal: Document extenuating circumstances delaying initial visit (patient/family request, medical instability, facility communication delays); provide admission date and medical necessity for timing
Service provided in non-qualifying facility setting (assisted living, residential care)
How to appeal: If facility is Medicare-certified SNF/NF, provide certification documentation and facility type verification; if truly non-qualifying setting, withdraw claim and rebill using appropriate domiciliary/rest home codes (99324-99328) or home visit codes
Frequently asked questions
What is the Medicare reimbursement rate for CPT code 99305 in 2025?
The 2025 Medicare national average reimbursement rate for CPT 99305 is $128.42 for both facility and non-facility settings. This rate is based on 3.97 total RVUs multiplied by the 2025 conversion factor of 32.3465.
Can I bill 99305 for a patient I've been treating in the hospital who transferred to a nursing facility?
Yes, 99305 is appropriate when you provide the initial comprehensive evaluation in the nursing facility setting, even if you previously treated the patient in the hospital. The nursing facility admission represents a new care setting requiring initial nursing facility care codes (99304-99306) based on complexity.
What is the difference between 99305 and 99304?
Both are initial nursing facility care codes, but 99305 requires moderate complexity medical decision-making while 99304 requires straightforward medical decision-making. 99305 pays $128.42 compared to approximately $92.48 for 99304, reflecting the higher complexity.
How many times can I bill 99305 for the same patient?
You can bill 99305 only once per patient per facility admission. After the initial visit, all subsequent visits during that stay must use subsequent nursing facility care codes (99307-99310). If the patient is discharged and re-admitted, a new initial visit code may be appropriate.
What documentation is required to support moderate complexity MDM for 99305?
You must document at least two of three MDM elements at moderate level: multiple problems with moderate progression/severity, moderate amount/complexity of data to review (such as independent interpretation of tests or discussion with external providers), or moderate risk of complications/morbidity. Include your assessment and care plan.
Can nurse practitioners and physician assistants bill 99305?
Yes, nurse practitioners and physician assistants can bill 99305 when performing initial nursing facility care within their scope of practice and state regulations. They may bill under their own NPI at 85% of the physician fee schedule rate or incident-to at 100% when requirements are met.
How long do I have to see a patient after nursing facility admission to bill 99305?
While Medicare doesn't specify an exact timeframe, initial nursing facility care should occur promptly after admission, typically within 24-48 hours. Delays should be documented with medical justification. Excessive delays may result in payers questioning whether the visit qualifies as initial care versus subsequent care.